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The efficacy of interventions to improve psychosocial outcomes following surgical treatment for breast cancer: a systematic review and meta-analysis Matthews, H, Grunfeld, EA & Turner, A Author post-print (accepted) deposited by Coventry University’s Repository Original citation & hyperlink:
Matthews, H, Grunfeld, EA & Turner, A 2016, 'The efficacy of interventions to improve psychosocial outcomes following surgical treatment for breast cancer: A systematic review and meta-analysis' Psycho-oncology, vol 26, no. 5, pp. 593-607 https://dx.doi.org/10.1002/pon.4199
DOI 10.1002/pon.4199 ISSN 1057-9249 ESSN 1099-1611 Publisher: Wiley This is the peer reviewed version of the following article: Matthews, H, Grunfeld, EA & Turner, A 2016, 'The efficacy of interventions to improve psychosocial outcomes following surgical treatment for breast cancer: A systematic review and meta-analysis' Psycho-oncology, vol 26, no. 5, pp. 593-607, which has been published in final form at https://dx.doi.org/10.1002/pon.4199. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving. Copyright © and Moral Rights are retained by the author(s) and/ or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders. This document is the author’s post-print version, incorporating any revisions agreed during the peer-review process. Some differences between the published version and this version may remain and you are advised to consult the published version if you wish to cite from it.
R E V I E W A R T I C L E
The efficacy of interventions to improve psychosocial
outcomes following surgical treatment for breast cancer: a
systematic review and meta‐analysis
Hannah Matthews* | Elizabeth A. Grunfeld | Andrew Turner
Faculty of Health and Life Sciences, Coventry
University, Coventry, UK
Correspondence
Hannah Matthews, Faculty of Health & Life
Sciences, Coventry University, Priory Street,
Coventry, UK, CV1 5FB.
Email: [email protected]
Abstract
Objective Breast cancer is the most commonly diagnosed cancer in women across the world.
The majority of women diagnosed with the disease undergo surgery, which is often associated
with significant psychosocial morbidity. The aim of this meta‐analysis was to identify the efficacy
of psychosocial interventions for women following breast cancer surgery.
Method A comprehensive literature search was undertaken using keyword and subject
headings within 7 databases. Included studies employed a quantitative methodology presenting
empirical findings focusing on interventions for female breast cancer patients following surgery.
Results Thirty‐two studies were included and based on conventional values of effect sizes.
Small effects emerged for the efficacy of psychosocial interventions in relation to anxiety
(Hedges g = 0.31), depression (0.38), quality of life (0.40), mood disturbance (0.31), distress
(0.27), body image (0.40), self‐esteem (0.35), and sexual functioning (0.22). A moderate to large
effect emerged for the efficacy of interventions in promoting improvements in sleep disturbance
(0.67). Clear evidence emerged for the efficacy of cognitive behavioral therapy in promoting
improvements in anxiety, depression, and quality of life.
Conclusion This is the first meta‐analysis to demonstrate the efficacy of interventions on a
range of psychosocial outcomes following breast cancer surgery. The meta‐analysis highlighted
that cognitive behavioral therapy was consistently the most effective psychosocial intervention
promoting improvements in anxiety, depression, and quality of life. However, there are short-
comings in existing studies; the length of the follow‐up period is typically short and the genera-
lizability of findings was limited by small samples, both of which should be addressed in future
studies.
KEYWOR D S
cancer, mastectomy, meta‐analysis, oncology, psychosocial interventions
1 | INTR ODUC TION
Breast cancer is the most commonly diagnosed cancer in women
across the world.1 It is estimated that 1 out of every 8 women will
develop breast cancer at some point in their lives.2 Mortality rates
have fallen over recent decades partly because of advances in early
detection and treatment,3 resulting in a growing cohort of breast
cancer survivors.4 Improved survival rates have placed increased
importance on promoting and supporting a high quality of life and
optimal psychosocial adjustment among breast cancer patients. The
primary treatment for breast cancer is surgical, consisting of either a
mastectomy or breast conservation surgery.1 Following mastectomy,
approximately one‐third of women choose to undergo immediate
breast reconstruction5 in order to reconstruct or reshape the breast
mound.
Breast cancer diagnosis and treatment is associated with increased
rates of anxiety, depression, distress, and reduced quality of life.6 The
period following breast cancer surgery is also associated with conside-
rable psychosocial morbidity7 with as many as 30% of women
experiencing anxiety and depression.6 Body image issues and sexual
difficulties are also significantly higher following surgical treatment for
breast cancer.8 However, it is often assumed that the distress expe-
rienced by women with breast cancer abates after the initial treatment,
yet stress‐related symptoms may actually increase after surgery and
treatment completion, as patients leave the “safety net” provided by
contact with the oncology team.7 A recent meta‐analysis suggested
anxiety after a diagnosis of cancer may persists for up to 10 years or
more.9 Collectively, these findings underscore the need to address
the psychosocial well‐being of breast cancer patients following surgical
treatment and reconstruction.
The past decade has seen an increase in the development of inter-
ventions to reduce psychosocial morbidity and improve coping and
adjustment following breast cancer treatment. Psychosocial interven-
tions are broadly defined as any supportive interaction involving 2 or
more individuals whose purpose is to promote awareness and
education, provide emotional support and encouragement, and assist
with problem solving.10 Psychosocial interventions that have been
utilized with breast cancer patients following surgery include group
therapy, individual counseling, psychotherapy, and psychoeducational
interventions.11,12 Generally, such interventions have only focused
on a limited number of patient outcomes, including anxiety, depres-
sion, and quality of life. Nevertheless, accumulating evidence indicates
psychosocial interventions provide a consistent beneficial effect for
cancer patients13 and specifically breast cancer patients.11 However,
little is known about which intervention is most effective following
breast cancer surgery. The aim of this systematic review and meta‐ analysis was to evaluate the efficacy of interventions on a range of
psychosocial outcomes following surgical treatment for breast cancer,
both mastectomy and breast conservation surgery.
2 | METHODS
2.1 | Search, selection, and review strategies
Two chartered health psychologists, a medical librarian, and a consul-
tant plastic surgeon formed part of the panel to develop an appropriate
search strategy. Four methods were used to identify relevant studies: a
keyword search, a subject search, a backward search, and a forward
search. Literature searches were performed using 7 electronic
databases: PsycINFO (1976‐2015), CINAHL (1998‐2015), MEDLINE
(1975‐2015), Academic Search Complete (1980‐2015), AMED (1996‐ 2014), Cochrane Library (1975‐2015), and EMBASE (1974‐2015).
The search terms were grouped into 3 blocks: block 1—breast
neoplasms, breast oncol*, breast cancer, breast tumor, and breast
tumour; block 2—mastectom*, lumpectom*, and prophylactic; and
block 3—family therap*, group therap*, psychosocial rehabilitation,
anxiety management, relaxation therap*, cognitive therap*, cognitive
behaviour*, therap*, social support, support groups, counsel*, counsel-
ling, counselling, group counsel, group counselling, and group counsel-
ling. The terms relating to the types of surgical procedures (block 2)
were combined with OR and NOT prophylactic, referring to prophylac-
tic mastectomy. Terms within each block were combined using OR,
and then the results of each block were combined using the AND
function. Duplicates were excluded. This study was approved by a
university ethics committee, and a review protocol was developed
and followed but is not available to access.
Inclusion criteria were as follows: (i) female adult breast cancer
survivors; (ii) any type of primary breast cancer surgery including
mastectomy and breast conservation surgery; (iii) psychological,
psychoeducational, and/or psychosocial intervention; (iv) written in
English; (v) quantitative methodology; and (vi) presenting empirical
findings. Studies were excluded if interventions focused on physical
rehabilitation, physiological outcomes, and palliative and/or meta-
static breast cancer and were published as a conference abstract
or a case study. A backward (reference) search was performed,
which involved hand searching the reference list of articles included
in the analysis. A forward (citation) search was also performed using
Scopus. Additionally, as part of the systematic search procedure,
review articles were also obtained and examined to identify any
additional articles.
Two blinded raters (H.M. and E.G.) independently applied a 14‐ item quality assessment checklist from a standardized quality assess-
ment tool to each study.14 Discrepancies were systematically resolved
by consensus. Each study was assessed against the 14 items using a 3‐ point scale (2 fully met, 1 partially met, and 0 did not meet the
criterion). A total score was calculated by summing the number of
“yes” responses, multiplying this by 2, and adding this to the number
of partials. If a criterion was not applicable, it was excluded from the
score calculation. The total possible score was calculated as 28 minus
2 times the number of not applicable. Lastly, a summary score (total
sum/total possible sum) was calculated, representing the methodolo-
gical quality of each article. These scores were calculated as a linear
score from 0 to 100 and divided into 3 categories representing low,
moderate, or high‐quality studies. Studies with a score of 75 or more
were considered as high quality, 50 to 74 as moderate quality, and
49 or less as low quality.
2.2 | Meta‐analysis strategy
We used Hedges g as the effect size statistic. Hedges g calculates
the difference between intervention and control group means (d)
divided by the pooled standard deviation multiplied by a factor (J)
that corrects the underestimation of the population standard deviation.15
Through pooling variances, Hedges g standardizes outcomes across
studies and allows for comparison among disparate outcome measures.
Effect size calculations used a random‐effects model. This assumes that
analyzed studies represent a random sample of effect sizes, subsequently
facilitating the generalizability of results.16 The heterogeneity between
studies was calculated using the heterogeneity I2 statistic. The I2 statistic
calculates what proportion (0‐100%) of the observed variance reflects
variance in true effect sizes, rather than sampling error. A value of 0%
represents no observed heterogeneity, and an I2 value of 25%, 50%, or
75% tentatively signifies low, moderate, or high heterogeneity between
studies, respectively.17 To minimize heterogeneity, when studies reported
outcomes at multiple time points, the furthest time point was used to
calculate effect size. We used the conventional values of effect size18 in
this analysis. An effect size of 0.2 demonstrated a small effect, 0.5 a
moderate effect, and 0.8 a large effect. We used the Comprehensive
Meta‐Analysis software for all statistical analyses.19
2.3 | Sources of bias
Mean effects for each outcome were assessed for the degree of
publication bias (the preferential publication of studies with positive
effects). Publication bias was assessed using two techniques: the
examination of the funnel plot and estimates of correction, trim and fill.
If the points on the funnel plot are evenly distributed between
positive and negative effects, bias is lacking within the meta‐analysis.
If publication bias exists, a disproportionate number of studies will fall
to the bottom right of the plot.20 The trim and fill method attempts to
estimate the number of missing studies that may exist in the meta‐ analysis and correct for funnel plot asymmetry.20 Orwin's fail‐safe
N was also calculated to assess the roboustness of the overall effect.21
This will determine the number of studies with a null effect size
required to reduce the overall effect to non‐significant. In this meta‐ analysis, the number of studies is represented by k.
2.4 | Systematic review results The search strategy identified 3817 records, reduced to 1455 unique
articles following the exclusion of duplicates and to 19 articles follo-
wing the application of the inclusion and exclusion criteria (Figure 1).
A backwards search identified 8 additional articles, and a forward
Searched electronic databases:
PsycINFO, CINAHL,
MEDLINE, Academic Search
Complete, AMED, Cochrane
Library and EMBASE. 3817
Studies obtained
Exclusion of duplicates 1455
Studies.
Review titles and abstracts of
search results.
Obtained full text of relevant
articles.
Exclusion of unsuitable
studies.
1376 studies were excluded
for the following reasons: a)
Abstract not relevant
b) Review paper
c) Comparative study
d) Case study
e) Conference or dissertation
abstract
f) Qualitative methodology
g) Prophylactic mastectomy
interventions.
Review full text of identified
articles.
Backward search
8 studies obtained
Forward search
7 studies obtained
2 low quality studies were
removed
Exclusion of irrelevant
studies
19 studies were included
42 excluded for these
reasons:
a) Full text was not relevant
b) Palliative or metastatic
c) Omission of mastectomy
patients
d) Decision aid interventions
e) Rehabilitation or
physiological interventions.
32 studies included in the review
FIGURE 1 Flow diagram depicting the systematic review process
search identified 7 further articles, totaling 34 articles. Twenty‐one
articles were classified as high quality, 11 as moderate quality, and 2
as low quality (Table 1). The two low‐quality articles were removed
from the review. In total, 32 articles were included in the review.
Twenty‐two studies utilized a randomized controlled trial design, 5
pre– and post–group evaluations, 2 nonrandomized controlled studies,
2 single cohorts pre‐evaluation and postevaluation, and 1 randomized
and comparative study design. Follow‐up periods ranged from 1 to
36 months with between 2 and 6 data collection points.
Participant and design characteristics of the 32 studies included in
this review are summarized in Table 1, and outcome and assessment
measures are described in detail in Table S3, accessible as supporting
information. This review comprised of 32 psychosocial interventions
with 8 studies utilizing cognitive behavioral therapy interven-
tions,10,22–28 7 psychoeducational interventions,29–35 4 support
groups,36–39 three counseling interventions,40–42 2 mindfulness‐based
stress reduction interventions,43,44 2 supportive‐expressive group
therapy interventions,45,46 1 psychosexual intervention,47 one music
therapy and progressive muscle relaxation training,48 and 1 contempla-
tive self‐healing intervention.49 The review also included 2 studies that
combined psychoeducational interventions and peer and social
support interventions50,51 and 1 intervention that combined cognitive
behavioral therapy, social support, and psychoeducational elements.52
Twenty‐five interventions were delivered in person, 6 interventions
were delivered via telephone, and 1 intervention via videoconferen-
cing. The number of intervention sessions ranged from a single session
to 30 sessions. The studies reported sample sizes ranging from 20 to
442, and the total number of participants across all studies included
in this review was 4148. Twenty‐nine of 32 studies reported signifi-
cant treatment effects in 1 or more examined outcomes.
2.5 | Anxiety
Eight of 13 studies reported a significant reduction in anxiety following
the intervention.23,27,39,44–48 While two studies demonstrated sig-
nificant effects with cognitive behavioral therapy on anxiety,23,27 2
studies reported no significant effects with cognitive behavioral
therapy.10,26 Counselling interventions also failed to demonstrate sig-
nificant treatment effects on anxiety.32,40,42 Moreover, Kimman and
colleagues32 reported no significant treatment effects of a telephone
educational intervention on anxiety.
2.6 | Depression
Thirteen studies reported a significant reduction in depression
across a range of interventions including cognitive behavioral the-
rapy,22,25–27 psychoeducational intervention,30 counseling,40 sup-
portive‐expressive group therapy,45,46 videoconferencing support
groups,36 psychosexual intervention,47 mindfulness‐based stress
reduction,44 support groups,39 and music therapy and progressive
muscle relaxation training.48 No significant treatment effect was
reported for telephone counseling,41 psychoeducation, and peer
modeling on depression.35
2.7 | Quality of life
Thirteen studies reported improved quality of life across a range of
interventions including contemplative self‐healing intervention,49
psychoeducational interventions,31 mindfulness‐based stress reduc-
tion,43 cognitive behavioral therapy,25–27,34,42 and combined interven-
tions utilizing psychoeducation, cognitive behavioral therapy, and
social support3 and a psychoeducational and peer support interven-
tion.50 Support groups37 and 2 psychoeducational interventions32,33
reported no significant treatment effects on quality of life.
2.8 | Mood disturbance
Five studies reported a significant improvement in mood with suppor-
tive‐expressive group therapy,45,46 mindfulness‐based stress reduc-
tion,43 telephone cognitive behavioral therapy,10 and counseling.42 In
contrast, 2 psychoeducational interventions reported no significant
treatment effect on mood disturbance.29,51
2.9 | Distress
In 2 psychoeducational interventions29,35 and a telephone counseling
intervention,41 no significant treatment effect was demonstrated in
lowering distress. In contrast, there were modest improvements in
distress after cognitive behavioral therapy,22 a support group interven-
tion,38 and a relaxation intervention,24 which all reported a significant
reduction in distress. However, 1 psychoeducational intervention
reported an increase in distress post intervention.29
2.10 | Body image
Two studies reported significant treatment effects with cognitive
behavioral therapy24 and support groups.37 In contrast, no significant
treatment effect on body image was observed for supportive‐expres-
sive group therapy.46
2.11 | Sleep disturbance
Two studies utilizing supportive‐expressive group therapy46 and
cognitive behavioral therapy27 reported improved sleep. One study
reported that a reduction in sleep disturbance was associated with
decreased anxiety and depression and improved global quality of life.31
2.12 | Self‐esteem
Group cognitive behavioral therapy reported a significant improve-
ment in self‐esteem.26,28 In contrast, studies utilizing support groups38
and couple counseling40 reported no significant treatment effects for
self‐esteem.
2.13 | Sexual functioning
Two studies reported significant improvements in sexual dysfunction
through counseling.40,41 The control group showed virtually no change
from baseline, suggesting that this source of psychosocial morbidity
may be especially resistant to improvement in the absence of
(Continues)
TABLE 1 Systematic review of psychosocial interventions for women after breast cancer surgery (k = 32)
Authors Study design
Sample
size Intervention Measures Outcomes
Quality
rating
Antoni et al, 2001, USA RCT Int: 46 Cognitive behavioral
therapy
The Profile of Mood
States Distress: 1.77,
F = 2.33 High
Comp: 53 Center for
Epidemiologic
Studies Depression
Scale
Life Orientation Test— Revised
Depression: Int,
Q = 13.60**;
Comp,
Q = 2.67
Optimism: Int
2.81; Comp
20.15,
F = 6.96***
Antoni et al, 2009, USA RCT Int: 63 Cognitive behavioral
therapy
Impact of Event Scale Anxiety:
F = 3.86* High
Comp: 65 Hamilton Rating Scale
for Anxiety
Affects Balance Scale
Intrusive
thoughts:
F = 3.24*
Ashing and Rosales, USA RCT Int: 100 Psychoeducational
intervention
Comp: 99
20‐item Center for Epidemiologic Studies Depression
Scale
Depression: Int
25.4 ± 17.2***;
Comp
14.8 ± 14.1*
(CI, −5.75 to
−0.282)*
High
Charlson et al, USA Pre– and post– group evaluation
Int: 46 Contemplative self‐ healing intervention
The Impact of Events
Scale
General Functional
Assessment of
Cancer Therapy
Scale + Breast
Cancer Subscale
Functional Assessment
of Chronic Illness
Therapy Spirituality
Scale
QoL: 4.6 ± 10.9* High
Spirituality:
+1.4 ± 1.0
Breast cancer–
specific QoL: +4.8 ± 12.8
Cho et al, Asia Nonrandomized
and comparative
Int: 28 Psychoeducational
intervention and
peer support
18‐item Psychosocial Adjustment Scale
Psychosocial
adjustment: Int
49.1 ± 52.1***;
Comp
50.3 ± 4.73
Moderate
Comp: 27 27‐item Quality of Life Scale
Christensen, USA RCT Int: 10 Couples counseling Locke‐Wallace Martial
Adjustment Test
Comp: 10 Sexual Satisfaction
Scale
Beck Depression
Inventory
Rosenberg Self‐esteem Scale
Spielberger State‐Trait
Anxiety Inventory
QoL: Int
6.2 ± 7.0**;
Comp 6.4 ± 6.3
Martial happiness:
Int 106.15;
Comp 99.6
Sexual
functioning: Int
80.41; Comp
69.04,
F = 33.92*
Depression: Int
98.18; Comp
12.02,
F = 7.53*
Self‐esteem: Int 17.5; Comp
17.8
Anxiety: Int 39.9;
Comp 40.5
Moderate
Classen et al, USA RCT Int: 178 Supportive‐expressive
group therapy
The Profile of Mood
States
Questionnaire
Mood: Int 13.69,
F = 4.7*; Comp
9.05, F = 6.5***
High
(Continues)
(Continues)
TABLE 1 (Continued)
Authors Study design
Sample
size Intervention Measures Outcomes Quality
rating
Comp:
179
The Hospital Anxiety
and Depression
Scale
Anxiety: Int,
F = 5.4*; Comp,
F = 6.3**
Yale Social Support
Index
Depression: Int,
F = 5.2*; Comp,
F = 5.3*
Social support: Int,
F = 6.0*; Comp
5.4*
Coleman et al., USA RCT Int: 54 Psychoeducational
intervention and
social support
Profile of Mood States Mood: NS High
Collie et al, USA Pre– and post– group evaluation
The Visual Analogue
Scale—Worry
Comp: 52 The Relationship
Change Scale
The 20‐item University
of California, Los
Angeles, Loneliness
Scale—Version 3
Int: 27 Support groups Center for
Epidemiologic
Studies Depression
Scale
The Cancer Behavior
Inventory
Courtauld Emotional
Control Scale
Cancer‐related
worry: NS
Relationships: NS
Loneliness: NS
Depression:
t = 2.44*;
d = 0.51
Emotional
expression:
t = 0.44
Self‐efficacy: t = 0.71
Moderate
Dow Meneses et al, USA RCT Int: 125 Psychoeducational
intervention
Comp:
131
QoL—Breast Cancer Survivors
QoL: Int −1.687;
Comp
−2.909***
High
Esplen et al, USA RCT Int: 128 Support groups Body Image Scale Body image: Int
18.3 ± 15.3;
Comp
18.5 ± 17.3*
High
Objectified Body
Consciousness
Scale
Comp: 65 Mental Adjustment to
Cancer Scale
Female Sexual
Function Index
Social Support
Survey
Functional Assessment of Cancer Therapy— Breast
Body stigma: Int
37.5 ± 34.3;
Comp
37.5 ± 37.4***
Sexual
functioning: Int
13.5 ± 15.2;
Comp
12.1 ± 12.7
QoL: Int
91.2 ± 94.8;
Comp
89.8 ± 92.4
Fadaei et al, Iran RCT Int: 32 Cognitive behavioral
therapy
Comp: 40
Body Image Scale Body image: Int
16.97 ± 9.03,
t = −6.07***;
Comp
15.95 ± 17.18
Moderate
Fobair et al, USA Single cohort
pre‐evaluation
and postevaluation
Int: 20 Supportive‐ expressive group therapy
The Impact of Event
Scale
Mood: t = −2.43* High
(Continues)
(Continues)
Authors Study design
Sample
size Intervention Measures Outcomes Quality
rating
The Profile of Mood
States
The Hospital Anxiety
and Depression
Scale
The Mini‐Mental Adjustment to Cancer
The Body Image and
Sexuality Scale for
Women With Breast
Cancer
The Family Relations
Index
The Social Network
and Support
Assessment
The Medical
Interaction Scale of
the Cancer
Rehabilitation
Evaluation System
The Impact of Illness
on Your Life
Questionnaire
Structured Insomnia
Interview
Anxiety:
t = −2.52*
Depression:
t = −3.11**
Coping:
t = −3.57**
Body image:
t = 0.71
Relationships:
t = −2.78**
Social support:
t = −2.42*
Impact of illness
on life:
t = −1.62
Sleep: t = 2.27*
Gunn et al, Australia Pre– and post– Int: 44 Support groups Profile of Mood States Distress: Moderate
group evaluation t = 3.44*** The Coopersmith Self‐
Esteem Inventory
The Duke‐UNC
Functional Social
Support
Questionnaire
Self‐esteem: t = −0.55
Social support:
t = 0.77
Hoffman et al, UK RCT Int: 103 Mindfulness‐based
stress reduction
Profile of Mood States Mood: CI, −21.02
to −4.81)***
High
Comp:
111
Jones et al, Canada RCT Int: 216 Psychoeducational
intervention
Comp:
226
Functional Assessment
of Cancer Therapy— Breast
WHO five‐item Well‐ being Questionnaire
Knowledge
Questionnaire
Perceived
preparedness for
reentry scale
Self‐Efficacy for
Managing Chronic Disease
QoL: CI, 4.16 to
10.68***
Well‐being: CI, 1.16 to 3.15***
Knowledge: 0.718
(CI, 0.418 to
1.017)***
Perceived
preparedness:
0.409 (CI, 0.273
to 0.545)***
Self‐efficacy: −0.221 (CI, −0.510 to
0.068)
High
Profile of Mood States Mood: 0.859 (CI,
−2.398 to
4.116)
Health Distress Scale Distress: 0.114
(CI, −0.035 to
0.262)
Kalaitzi et al, Greece RCT Int: 20 Psychosexual
intervention
Spielberger's State‐ Trait Anxiety Inventory
Depression: Int
<0.001***;
Comp: P < .236
Moderate
(Continues)
(Continues)
Sample Quality
Authors Study design size Intervention Measures Outcomes rating
Comp: 20 Center for
Epidemiologic
Studies Depression
Scale
Questionnaire
assessing sexuality
and body image
Anxiety: Int,
P < .006**;
Comp, P < .645
Kimman et al, the Netherlands RCT Int: 149 Psychoeducational
intervention
EORTC QoL
Questionnaire
QoL: NS High
Comp: State‐Trait Anxiety Anxiety: NS 150 Inventory Kionberg et al, Sweden Nonrandomized Int: 50 Psychoeducational The Functional Well‐being: NS High
controlled study intervention Assessment of Cancer Therapy General Scale Comp: 46 Sense of Coherence Sense of Scale coherence: NS
Lengacher et al, USA RCT Int: 41 Mindfulness‐based 30‐item Concerns Fear of High
stress reduction about Recurrence recurrence: Int Scale 9.3; Comp 11.6** Comp: 43 The State‐Trait State anxiety: Int
Manos et al, Spain Nonrandomized
controlled study
Int: 94 Psychoeducational
intervention and
cognitive behavioral
therapy and social
support
Anxiety Inventory
Epidemiological
Studies Depression
Scale
6‐item Life Orientation Test
10‐item Perceived
Stress Scale
19‐item Medical
Outcomes Social Support Survey
EORTC QoL
Questionnaire
28.3; Comp 33.0*
Depression: Int
6.3; Comp 9.6*
Optimism: Int
46.7; Comp
44.9
Perceived stress:
Int 12.6; Comp
14.4
Social support:
Int 12.4; Comp
12.8
QoL:
F = 25.173**
Anxious
preoccupation:
F = 16.036**
Moderate
Comp: 94 Mental Adjustment to
Cancer Scale
Fighting spirit:
F = 55.345**
Optimism:
F = 18.413**
Marchioro et al, Italy RCT Int: 18 Cognitive behavioral
therapy
Functional Living
Index Cancer QoL: Int 41.17;
Comp 60.28***
Moderate
Comp: 18 The Beck Depression
Inventory
Depression: Int
4.83; Comp
8.17***
Marcus et al, USA RCT Int: 152 Counseling Impact of Event Scale Distress: P = .29;
r = 0.24 High
Comp:
152
Center for
Epidemiologic
Studies Depression
Scale
The Sexual
Dysfunction Scale
Depression:
P = .48; r = 0.23
Sexual
functioning:
P = .04;
r = 0.23*
(Continues)
(Continues)
Authors
Study design
Sample
size
Intervention
Measures
Outcomes
Quality
rating
Montazeri et al, Iran Single cohort
pre‐evaluation
Int: 56 Support groups The Hospital Anxiety
and Depression
Anxiety: t = 2.21* Moderate
and
postevaluation
Qui et al, China RCT Int: 31 Cognitive behavioral
therapy
Scale
17‐item Hamilton
Depression Rating Scale
Self‐rating Anxiety
Scale
Depression:
t = 2.75**
Depression: Int
7.51; Comp
14.35
(ES = 1.51)***
Anxiety: Int
37.74; Comp
43.10 (ES =
0.66)
High
Comp: 31 Functional Assessment
of Cancer Therapy— Breast
Self‐esteem: Int 28.42; Comp
27.00
(ES = 0.63)* Self‐esteem Scale QoL: Int 97.17;
Comp 89.85
(ES = 0.53)**
Sandgren et al, USA RCT Int: 24 Cognitive behavioral Coping Response Distress: Int 8.2; High
therapy Indices—Revised Comp 7.4,
F = 4.48*
Comp: 29 Profile of Mood States Coping cognitive: Int 28.9; Comp 26.7
Coping behavioral: Int 31.5; Comp 20.8
Coping avoidant: Int 11.2; Comp 12.0
Anxiety: Int 2.9; Comp 3.6, F = 6.29*
Mood: Int 2.0; Comp 3.0, F = 3.15*
Savard et al, Canada RCT Int: 27 Cognitive behavioral Insomnia Severity Sleep: High
therapy Index F = 11.70***
Hospital Anxiety and Anxiety: Depression Scale F = 5.19*
Comp: 30 EORTC QoL Depression: Questionnaire F = 4.14*
Sharif et al, Iran RCT Int: 49 Psychoeducational
intervention
EORTC QoL
Questionnaire
QoL: F = 5.69*
QoL: Int 80.0;
Comp 61.66***
High
Comp: 50
Stanton et al, USA RCT Int: 143 Psychoeducational
intervention
Comp:
136
4‐item Short‐Form
Vitality Subscale
Revised Impact of
Events Scale
Center for
Epidemiologic
Studies Depression
Scale
Vitality: Educ
7.36; Comp
6.60
Distress: Educ
−0.07; Comp
−0.08
Depression: Educ
−0.68; Comp
−1.79
High
(Continues)
0.95 to 6.52);
t = 2.64**
Watson et al, UK Pre– and post– group evaluation
Int: NR Counseling Profile of Mood States Mood: Int,
t = 2.98*;
Comp, t = 2.3*
Moderate
Comp:
NR Spielberger State‐Trait
Anxiety Inventory
Anxiety: Int 0.5;
Comp 4.5
Wojtyna et al, Poland Pre– and post– group evaluation
Int: 35 Cognitive behavioral
therapy
EORTC QoL
Questionnaire
QoL: Int 64.76;
Comp 54.86,
F = 6.33*
Moderate
Depression 12 0.38 0.24–0.52 0.001 Q = 21.52, p = 0.04, I2 = 44.23 198
Anxiety 10 0.31 0.19–0.43 0.001 Q = 12.71 p = 0.24, I2 = 21.33 81
Quality of Life 10 0.40 0.27–0.54 0.001 Q = 20.48 p = 0.04, I2 = 46.29 189
Body Image 3 0.40 0.16–0.63 0.001 Q = 21.68 p = 0.33, I2 = 7.74 7
Sexual functioning 3 0.22 0.07–0.50 0.14 Q = 3.63, p = 0.16, I2 = 44.89 2
Sleep disturbance 2 0.67 0.29–1.05 0.001 Q = 1.19 p = 0.27, I2 = 16.52 N/A
Self‐esteem 3 0.35 0.00–0.69 0.05 Q = 4.14 p = 0.12, I2 = 51.71 4
Mood disturbance 4 0.31 0.12–0.51 0.001 Q = 8.95 p = 0.06, I2 = 55.33 35
Distress 5 0.27 0.05–0.49 0.02 Q = 11.41 p = 0.01, I2 = 73.72 9
Authors Study design
Sample
size Intervention Measures Outcomes Quality
rating
Posttraumatic Growth
Inventory
Perceived
preparedness for
reentry
Posttraumatic
growth: Educ
5.44; Comp
2.43
Perceived
preparedness:
B = 3.73 (CI,
Comp: 32 R. Cibor's Self‐esteem
Scale
Self‐esteem: Int 27.06; Comp
32.91, F = 4.46*
Zhou et al, China RCT Int: 85 Music therapy and
progressive muscle
relaxation training
Zung Self‐rating Depression Scale
Depression:
38.29 ± 32.65,
F = 6.91**
High
Comp: 85
State Anxiety
Inventory
Anxiety:
53.98 ± 41.06,
F = 5.46*
Abbreviations: EORTC, European Organisation for Research and Treatment of Cancer; NS, not significant; QoL, quality of life; RCT, randomized controlled trial.
Bold emphases indicate primary study outcomes. *P < .05. **P < .01. ***P < .001.
intervention.41 However, Esplen and colleagues37 reported no signifi-
cant treatment effects with support groups and sexual functioning.
2.14 | Meta‐analysis results
Weighted average effect sizes for each outcome are displayed in
Table 2, and forest plots are displayed in Figure 2. Additionally,
Table 2 details results of analyses to detect publication bias and
heterogeneity statistics for each of the psychosocial outcomes.
Meta‐regression indicated that the number of sessions within an inter-
vention was not a significant moderator of depression (k = 10;
B = 0.006; P = .49), nor was quality of life (k = 11; B = −0.016;
P = .08). However, the number of sessions was a significant moderator
for anxiety (k = 9; B = 0.015; P = .04). In regard to publication bias, all
funnel plots displayed a greater number of studies to the right of the
mean. However, as a disproportionate number of studies did not fall
to the bottom right of the plot, this suggests systematic bias does
not significantly contribute to our estimate of the efficacy of interven-
tions in relation to psychosocial outcomes. Funnel plots are displayed
in Figure S3, accessible online via supporting information. Trim and fill
procedures inputted 5 studies for depression, 1 study for anxiety, 4
studies for quality of life, 1 study for sexual functioning, and 2 studies
for mood disturbance and distress, and no studies were inputted for
self‐esteem and body image. Orwin's fail‐safe N was calculated to
assess the robustness of the overall effect for each outcome. Orwin's
fail‐safe N indicated 198 nonsignificant studies for depression, 81 for
TABLE 2 Mean effect sizes for psychosocial outcomes for studies with sufficientdata for the meta‐analysis
Psychosocial outcome k Effect size (g) 95% CI p‐value Heterogeneity Fail‐safe N
Meta-Analysis: Depression
Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value
Ashing 2014 0.40 0.14 0.02 0.12 0.68 2.82 0.00
Christensen 1983 0.90 0.45 0.20 0.02 1.78 1.99 0.05
Classen 2008 0.21 0.11 0.01 0.00 0.42 1.98 0.05
Collie 2007 0.53 0.20 0.04 0.14 0.93 2.66 0.01
Lengacher 2009 0.48 0.22 0.05 0.05 0.91 2.18 0.03
Marchioro 1996 1.17 0.35 0.13 0.48 1.87 3.31 0.00
Marcus 2009 0.22 0.11 0.01 -0.01 0.44 1.88 0.06
Montazeri 2001 0.36 0.14 0.02 0.10 0.63 2.66 0.01
Qui 2013 0.63 0.27 0.07 0.10 1.16 2.34 0.02
Savard 2005 0.53 0.27 0.07 0.01 1.05 2.00 0.05
Stanton 2005 0.01 0.12 0.01 -0.22 0.25 0.12 0.91
Zhou 2015 0.51 0.16 0.02 0.21 0.82 3.30 0.00
0.38 0.07 0.00 0.24 0.52 5.41 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improvement of outcome
Meta-Analysis: Anxiety
Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value
Antoni 2009 0.35 0.18 0.03 -0.00 0.69 1.95 0.05
Classen 2008 0.26 0.11 0.01 0.06 0.47 2.49 0.01
Fobair 2002 0.55 0.23 0.05 0.09 1.00 2.36 0.02
Kimman 2011 0.01 0.12 0.01 -0.21 0.24 0.10 0.92
Lengacher 2009 0.48 0.22 0.05 0.05 0.92 2.18 0.03
Montazeri 2001 0.29 0.13 0.02 0.03 0.56 2.16 0.03
Qui 2013 0.13 0.26 0.07 -0.37 0.63 0.52 0.60
Sandgren 2000 0.41 0.27 0.08 -0.13 0.95 1.48 0.14
Savard 2005 0.60 0.27 0.07 0.07 1.12 2.23 0.03
Zhou 2014 0.51 0.16 0.02 0.21 0.82 3.30 0.00
0.31 0.06 0.00 0.19 0.43 4.95 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improvement of outcome
FIGURE 2 Forest plots of effect sizes for studies assessing psychosocial outcomes
anxiety, and 189 for quality of life would be required to render the
efficacy of the interventions trivial. The Orwin fail‐safe N analysis for
all outcomes is displayed in Table 2.
3 | DISCUSSION
To our knowledge, this is the first meta‐analysis to evaluate the
efficacy of interventions on a range of psychosocial outcomes in
breast cancer patients. The meta‐analysis demonstrated small effect
sizes on 8 psychosocial outcomes: anxiety, depression, quality of life,
mood disturbance, distress, body image, self‐esteem, and sexual
functioning. A moderate to large effect size was detected on sleep
disturbance. Within this meta‐analysis, anxiety (k = 14), depression
(k = 14), and quality of life (k = 13) were the most commonly reported
outcomes. This is not surprising given the high incidence of anxiety
and depression after surgical treatment for breast cancer, with as
many as 30% of women reporting experiencing anxiety and depres-
sion,6 and the widely recognized impact of anxiety and depression
on quality of life.7 Moreover, cognitive behavioral therapy was the
most common intervention for both anxiety and depression, often
reporting significant treatment effects.22,23,25–27 This meta‐analysis
provides clear evidence for the efficacy of cognitive behavioral
therapy in improving outcomes in relation to anxiety,10,23,37,39
depression,22,25,26,37 and quality of life.25–28 Meta‐regression indi-
cated the number of sessions was not a significant moderator of
depression or quality of life, although we can conclude the number
of sessions is related to effect size for the outcome anxiety. How-
ever, we cannot conclude if the length of the sessions moderated
the effect size or the timing of the intervention or who delivered
the intervention, as a large portion of the studies did not report
significant details of the interventions. This should be addressed in
future research to develop effective evidence‐based interventions
to enhance breast cancer care.
A previous meta‐analysis demonstrated the efficacy of cognitive
behavioral therapy following treatment for adult cancer survivors on
anxiety, depression, and quality of life with a large effect size
(g = 1.99), based on 4 studies.52 The findings of this meta‐analysis
are conservative yet consistent with previous literature. Moreover, a
meta‐analysis assessing the efficacy of psychological interventions
for breast cancer patients reported strong treatment effects for the
efficacy of cognitive behavioral therapy in improving anxiety, depres-
sion, and quality of life.53 This meta‐analysis is the first to demonstrate
the efficacy of psychosocial interventions to improve a range of
psychosocial outcomes following breast cancer surgery. Previous
literature52 has predominately focused on anxiety, depression, and
quality of life. While these are undoubtedly important outcomes, our
meta‐analysis goes beyond this and considers less explored yet emer-
ging research outcomes. However, this meta‐analysis cannot conclude
if the period following breast cancer surgery is optimal to provide
support for breast cancer patients; this warrants further investigation.
Moreover, it is not clear for the other psychosocial outcomes which
Study name
Meta-Analysis: Quality of Life
Statistics for each study
Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Hedges's g and 95% CI
Charlson 2014 0.39 0.15 0.02 0.09 0.69 2.59 0.01
Cho 2006 0.89 0.28 0.08 0.34 1.44 3.19 0.00
Dow Meneses 2007 0.29 0.13 0.02 0.05 0.54 2.32 0.02
Esplen 2012 0.08 0.15 0.02 -0.22 0.37 0.50 0.62
Hoffman 2012 0.45 0.14 0.02 0.18 0.73 3.29 0.00
Kimman 2011 0.09 0.12 0.01 -0.13 0.32 0.81 0.42
Manos 2008 0.38 0.15 0.02 0.09 0.67 2.58 0.01
Marchioro 1996 0.97 0.35 0.12 0.29 1.65 2.81 0.00
Qui 2013 0.50 0.25 0.06 -0.00 1.00 1.95 0.05
Savard 2005 0.52 0.27 0.07 0.00 1.05 1.97 0.05
Sharif 2006 0.68 0.21 0.04 0.27 1.08 3.30 0.00
Wojtyna 2007 0.61 0.25 0.06 0.12 1.09 2.46 0.01
0.36 0.05 0.00 0.26 0.45 7.26 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Increase of Outcome
Meta-Analysis: Body Image
Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Esplen 2012 0.43 0.17 0.03 0.10 0.76 2.58 0.01
Fadaei 2010 0.62 0.24 0.06 0.15 1.09 2.59 0.01
Fobair 2002 0.15 0.22 0.05 -0.27 0.58 0.72 0.47
0.40 0.12 0.01 0.16 0.63 3.26 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improvement of outcome
Meta-Analysis: Sleep distrubance
Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Fobair 2002 0.50 0.23 0.05 0.05 0.95 2.20 0.03
Savard 2005 0.89 0.27 0.08 0.36 1.43 3.26 0.00
0.67 0.19 0.04 0.29 1.05 3.46 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improvement of outcome
Meta-Analysis: Self-esteem
Study name
Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value
Gunn 2005 0.09 0.15 0.02 -0.20 0.38 0.58 0.56
Qiu 2013 0.60 0.26 0.07 0.10 1.10 2.34 0.02
Wojtyna 2007 0.51 0.25 0.06 0.03 0.99 2.08 0.04
0.35 0.18 0.03 0.00 0.69 1.97 0.05
-1.00 -0.50 0.00 0.50 1.00
Improvement of outcome Decline of outcome
FIGURE 2 (Continued)
intervention would be most effective; this should be addressed in
future studies. Consequently, robust conclusions cannot be drawn
surrounding which intervention would be most effective for specific
psychosocial outcomes, with the exception of cognitive behavioral
therapy improving outcomes in relation to anxiety, depression, and
quality of life.
The quality of both the systematic review and meta‐analysis is
dependent on the quality of studies analyzed. One review suggests
the more rigorous the review, the less likely it is to conclude there
is evidence that psychosocial interventions in oncology are
effective.54 Consequently, the design of the studies included must
be considered. While the majority of studies utilized a randomized
controlled trial study design, a number of studies employed a pretest
and posttest design. Therefore, in the studies that employed a pre-
test and posttest design, the findings may be attributed to changes
that occurred independently to the intervention; for example,
Meta-Analysis: Mood distrubance
Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value
Classen 2008 0.35 0.11 0.01 0.14 0.56 3.29 0.00
Fobair 2002 0.50 0.23 0.05 0.05 0.95 2.20 0.03
Hoffman 2012 0.45 0.14 0.02 0.18 0.73 3.29 0.00
Jones 2011 0.11 0.08 0.01 -0.04 0.26 1.41 0.16
0.31 0.10 0.01 0.12 0.51 3.15 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improvement of outcome
Meta-Analysis: Distress
Study name Statistics for each study Hedges's g and 95% CI
Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value
Antoni 2001 0.31 0.20 0.04 -0.09 0.70 1.52 0.13
Gunn 2005 0.52 0.16 0.03 0.21 0.83 3.31 0.00
Jones 2013 0.02 0.05 0.00 -0.09 0.12 0.33 0.74
Marcus 2010 0.21 0.11 0.01 -0.02 0.43 1.81 0.07
Sandgren 2000 0.57 0.28 0.08 0.03 1.12 2.06 0.04
0.27 0.11 0.01 0.05 0.49 2.35 0.02
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improvement of outcome
FIGURE 2 (Continued)
increased support from family members may improve psychosocial
well‐being. A number of studies acknowledge an absence in ran-
domization and/or the process of randomization did not result in
equity between groups. Therefore, further evidence with random-
ized controlled trial study designs may be required to confirm signif-
icant treatment effects are not linked to weaker study design. This
meta‐analysis did not include unpublished studies, as we considered
published peer‐reviewed studies would provide the strongest evi-
dence regarding the efficacy of psychosocial interventions. How-
ever, we recognize effect sizes may be overestimated with the
absence of publication of null findings. This review also reported
both primary and secondary outcomes of studies within the meta‐ analysis. Subsequently, we acknowledge the possibility of reporting
small effect sizes for secondary outcomes. Seven studies were
excluded because the published data were not suitable for meta‐ analysis, and the required data could not be obtained from the
authors.11,23,25,37,39,44,48
The studies included in this meta‐analysis present a number of
limitations. The majority of the studies recruited a sample of highly
educated, middle‐class White women who were likely to be moti-
vated to participate in health research. Furthermore, 3 studies26,30,45
utilized samples with clinically depressed and highly distressed partic-
ipants, and another study included women experiencing chronic
insomnia.27 Consequently, a significant improvement is more likely,
as participants who experience considerable psychological symptoms
may be more likely to engage in interventions and hence benefit more
from the intervention, enhancing the likelihood of detecting signifi-
cant treatment effects.55 We recommend that researchers should be
aware of the sample when assessing the findings. Future studies
may want to consider screening for psychological symptoms and
including only those participants with elevated scores. This would
allow for resources to be targeted at those who would benefit most
from the intervention and reduce the likelihood of bias from the
ceiling/floor effects.
Seven studies acknowledged limited generalizability from small
sample sizes (n < 50) and hence were underpowered to evaluate
changes in the multiple outcomes that were measured.25,36,38,40,46,47,49
Notably, studies with low statistical power have a reduced chance of
detecting a true effect.56 A number of studies also reported limited
generalizability from single‐center trials, and the use of a single highly
trained therapist within the interventions. Furthermore, many of the
interventions included multiple components; subsequently, it is often
not possible to determine which component an improvement is attrib-
utable to. As Czaja and colleagues58 acknowledged, the decomposition
of psychosocial interventions to identify effective components is an
important goal within the field of psycho‐oncology and should be
addressed in future studies. Moreover, no studies included in this
meta‐analysis evaluated the cost‐effectiveness of interventions. How-
ever, there is a pressing need for studies to address cost issues for
breast cancer interventions to determine if the initial intervention cost
becomes cost‐effective over time.56 For example, a reduction in the
number of general practitioner visits may result in overall cost‐effec-
tiveness of an intervention.57 We recommend future investigators to
consider the cost‐effectiveness of interventions, particularly consider-
ing different modes of administration (ie, in person or over the phone)
to provide efficient and cost‐effective support.
This is the first meta‐analysis to evaluate the efficacy of interven-
tions to improve a range of psychosocial outcomes following breast
cancer surgery. This meta‐analysis has demonstrated the efficacy of
cognitive behavioral therapy in improving outcomes in relation to
anxiety, depression, and quality of life. This meta‐analysis is of signifi-
cant importance given the potential widespread integration of
evidenced‐based psychosocial interventions in clinical cancer care.
Future research priorities should focus on strengthening studies both
conceptually and methodologically, to meaningfully pool data to
determine which intervention components are required to enhance
breast cancer survivorship. Currently, robust conclusions cannot be
determined regarding the efficacy of different types of psychosocial
interventions. However, this meta‐analysis provides a methodical,
novel, and secure evidence base for the efficacy of cognitive beha-
vioral therapy on anxiety, depression, and quality of life following
breast cancer surgery.
FUND ING
This research received no specific grant from any funding agency in the
public, commercial, or not‐for‐profit sectors. It was completed as part
of a doctoral program of study.
CONF LICT OF INTE R E S T
No conflict of interest has been declared by the author(s).
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SUPPO R TI NG INF O RMATI O N
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How to cite this article: Matthews, H., Grunfeld, E. A., and
Turner, A. (2016), The efficacy of interventions to improve psy-
chosocial outcomes following surgical treatment for breast
cancer: a systematic review and meta‐analysis, Psycho‐Oncol-
ogy, doi: 10.1002/pon.4199
